3867 (12/2016)
Tips For Claim Submission
An eligible dependent is defined as a spouse, qualifying child, or
qualifying relative.
A qualifying child is defined as a tax dependent child up to age
26 or any age if permanently disabled.
A qualifying relative is someone who resides with you for
more than half of the year.
Qualifying children and relatives must not provide more than
half of his/her own support.
For a complete list of eligible expenses specific to your plan,
log in to your account at takecareWageWorks.com and select
“Eligible Expense” from the left side of the screen. Only submit
claims for eligible expenses.
A letter of medical necessity is required for any expense listed
as “Yes (Letter)” on the eligible expense list to establish medical
necessity. Cosmetic surgery or procedures, e.g., teeth whitening,
are not eligible expenses unless deemed as medically neces-
sary by a licensed physician. A letter of medical necessity form
can be obtained at:
http://www.takecareWageWorks.com/ee/ee_fac.html.
Tip for Over-the-Counter Expenses
A prescription is required for any over-the-counter expense
listed as “Yes (Rx)” on the eligible expense list. As a result
of the Health Care Reform Law, in addition to the required
detailed receipt, an actual prescription written by a doctor (on
a prescription pad or form) dated on or before the date the
expense was incurred is required to verify that the over-the-
counter medicine is prescribed for a known medical condition.
Tips For Documentation
Ensure that the documentation is legible.
Cancelled or copies of checks and credit card receipts do not
contain all 6 required pieces of information needed to approve
your expense, and are not acceptable for submission.
Explanation of Benefits (EOBs) are recommended, especially if
your insurance covered a portion of the expense.
The use of a highlighter causes items to not be legible on the
documentation; highlighter use is not recommended.
Send only photocopies of your claim form and documentation
keep the originals for your records if submitting via US Mail.
Your provider may sign the form confirming the date of services,
charges, and other service or product information in lieu of
providing separate documentation or other proof of service.
Tips For Faxing
Do not use a cover page when faxing the claim form and
documentation.
Submit only claims for your own account.
Tips for Viewing Claim Status
Please allow 2 business days from receipt of your claim for
processing.
You will be notified via email of the status of your claim if we
have a valid email address on file (to update your email address,
please log into your account at takecareWageWorks.com and
select “Profile” in the upper right corner of the screen).
HEALTHCARE ACCOUNT
How to File a Claim for Approval
Instructions to fill out this form:
Complete ALL account holder information.
Provide your employer name without
abbreviation.
Use your documentation to complete
each section of the form, including the
following:
Provider Name
Service Date(s)
Patient Name and Relationship
to Account Holder
Type of Service
Patient Responsibility
Provider Signature is
not required
,
but can replace need for other proof
of service
SM I T H JOHN
JONES GRA PH I CS
5421
10063
Mercy Hospital
Dr. Mark Johnson, M.D.
Mercy Pharmacy
010515
010515
011415
011415
John Smith
Mary Smith
2 5 0 0
1 0 70
Claim Filing Options:
File claim online: Log in to your account at takecarewageworks.com to submit your claim electronically.
File claim via fax, email, or mail: Claim details may be entered online and a completed form may be printed and faxed or
mailed with documentation. Fax: 877-782-8889, US Mail: CLAIMS ADMINISTRATOR, PO Box 14054, Lexington, KY, 40512,
Email: claims@takecareclaims.com
3867 (12/2016)
File claim online: Join the growing majority of participants who submit their claim online for faster service. Log in to your
account at takecareWageWorks.com to file your claim electronically and upload your documentation.
File claim via fax, email, or mail: Claim details may be entered online and a completed form may be printed and faxed or
mailed with documentation. Fax: 877-782-8889, US Mail: CLAIMS ADMINISTRATOR, PO Box 14054, Lexington, KY, 40512,
Email: claims@takecareclaims.com
Claim processing time: Claims will be processed within 2 business days after WageWorks receives the form. You may check
the status of your claim by logging in to your account at takecareWageWorks.com.
CERTIFICATION AND AUTHORIZATION: I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible expenses
incurred by myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) If the expense(s) claimed
is covered under my Employer's Health Reimbursement Arrangement, I certify that the patient for each claim being submitted is covered under an Aordable Care Act compliant
employer-sponsored group medical plan (their own, mine, or my spouse's). I have already received these products and services and confirm that by requesting reimbursement here
that I have not and will not seek reimbursement of this expense from any other plan or party. If I am covered under more than one healthcare account, reimbursement will be made
according to the payment order determined by those plans and as stated on the WageWorks website. Use of this service indicates my acceptance of the WageWorks User Agreement
at takecareWageWorks.com (available upon log in; enter User Name and Password or click on New User Registration)
HEALTHCARE ACCOUNT
Pay Me Back Claim Form
ACCOUNT HOLDER:
Last Name First Name
Employer Name
Last 4 of SSN Zip Code
PROVIDER NAME
SERVICE DATES
(Start and End Dates)
(MM/DD/YY)
PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER,
AND TYPE OF SERVICE
OUT-OF-POCKET
COST
Patient Name: ___________________________________________________________
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Signature of Provider:
(Replaces the need for other proof of service.)
Patient Name: ___________________________________________________________
Signature of Provider:
(Replaces the need for other proof of service.)
More expenses? Please complete another form. CLAIM FORM TOTAL:
Relationship to Account Holder:
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Co-payment
Dental Vision
Med Deductible OTC
Medical Fee Oce Visit
Coinsurance
Other ___________________________
$
.
,
$
.
,
$
.
,
$
.
,
$
.
,
Relationship to Account Holder:
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Co-payment
Dental Vision
Med Deductible OTC
Medical Fee Oce Visit
Coinsurance
Other ___________________________
Relationship to Account Holder:
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Co-payment
Dental Vision
Med Deductible OTC
Medical Fee Oce Visit
Coinsurance
Other ___________________________
Relationship to Account Holder:
Self
Spouse
Qualifying Child
Qualifying Relative
Other: _________________
Type of Service:
Rx Co-payment
Dental Vision
Med Deductible OTC
Medical Fee Oce Visit
Coinsurance
Other ___________________________
0